LAMPIRAN 2

Tabel Analisis Kelengkapan Penulisan Diagnosa Utama Dan Ketepatan Pengkodean

N No. Diagnosa Utama Diagnosa Utama Lengkap Tidak Kode Kode Peneliti ICD 10
o Rekam Ringkasan Keluar Pada Resume Lengkap RS
Medis Medis
1 05.83.28 Fraktur Clavicula 2/4 Kiri Fraktur Clavicula √ S42.0 S42.00 Fracture of Clavicle closed
Tertutup 2/4 Kiri Tertutup
2 05.99.28 Fraktur Collum Femoris - √ S72.9 S72.90 Fracture of femur, part unspecified
Kanan closed
3 05.53.42 Fraktur Fibula Dextra Fraktur os Fibula √ S82.4 S82.40 Fracture of fibula alone closed
Dextra 1/3
tertutup
4 05.50.24 Fraktur Digiti 3 Maximus Fraktur Digiti 3 √ S62.6 S62.60 Fracture of other finger closed
Sinistra dan 4 Manus
Sinistra
5 05.53.87 Trauma Capitis Trauma Capitis √ S00.9 S09.9 Unspecified injury of head
6 04.24.20 Coller Fraktur Dextra Coller Fraktur √ S42.0 S42.00 Fracture of clavicle closed
Dextra
7 05.45.97 Fraktur Fibula Sinistra Fraktur Fibula √ S82.4 S82.41 Fracture of fibula alone open
Terbuka Grade III Sinistra Terbuka
Grade III
8 05.49.42 Fraktur Mandibula - √ S02.6 S02.60 Fracture of mandible closed
9 05.49.74 Fraktur Distal Phalax Digit - √ S62.5 S62.51 Fracture of thumb open
I Manus Sinistra Grade 3
10 05.49.97 Fraktur Clavicula 1/3 Fraktur Clavicula √ S42.0 S42.00 Fracture of clavicle closed
Lateral Tertutup 1/3 Lateral
Tertutup
11 05.49.41 Fraktur Clavicula 1/3 - √ S42.0 S42.00 Fracture of clavicle closed
Medial
12 05.49.36 Fraktur Distal IV Phalax - √ S92.5 S62.61 Fracture of other finger open
distal tangan Sinistra

2
 LAMPIRAN 2

13 06.22.60 Haemorhoid internal Grade Haemorhoid √ I84.2 I84.2 Internal haemorrhoids without
III internal Grade III complication
14 01.24.46 Fraktur Compressi L1 Fraktur √ S32.0 S32.00 Fracture of lumbar vertebra
Compressi L1
15 01.24.46 Hypertensi Hypertensi √ I10 I10 Essential (primary) hypertension
16 05.57.65 Close Fraktur Right Neck Close Fraktur √ S42.0 S42.00 Fracture of clavicle closed
Scapula Right neck
Scapula
17 05.54.61 Trauma Capitis Ringan - √ S00.9 S09.9 Unspecified injury of head
18 05.54.50 Neurofibroma Multiple Neurofibroma √ Q85.0 Q85.0 Neurofibromatosis (nonmalignant)
Multiple
19 05.55.42 Appendisitis akut Appendisitis akut √ K35.9 K35.9 Acute Appendicitis, unspecified
20 05.58.56 Perdarahan pada gusi or Periodontitis akut √ K05.1 K05.0 Acute gingivitis
periodontitis akut x dan Gingivitis
gingivitis akut akut
21 05.56.20 Mammae Acessories dextra Mammae √ Q83.1 Q83.1 Accessory breast
acessories dextra
22 05.58.57 Fleura Efusion - √ J90 J90 Pleura effusion, not elsewhere
classified
23 04.13.75 Tumor Mammae Kiri - √ D24 D24 Benign neoplasma of breast
Gland Medialisis
24 00.29.01 Abces Besar Gluterus Kiri Abcess besar √ L02.3 L02.3 Cutaneous abscess, furuncle and
gluterus kiri carbuncle of buttock
25 05.60.22 Phimosis + Chancroid Phimosis+ √ A57 A57 Chancroid
Chancroid
26 05.62.65 Appendicitis Chronic Exa Appendicitis akut √ K36 K35.9 Acute Appendicitis, unspecified
Akut
27 05.64.35 cholelitiasis Cholelitiasis √ K80.2 K80.2 Calculus of gallbladder without
cholecystitis
28 05.63.96 SoftTissue Contusion Paha Softtissue √ S70.1 S70.1 Contusio of thigh
Kiri Distal contusion paha
kiri distal

3
 LAMPIRAN 2

29 05.63.65 Trauma capitis Ringan Trauma capitis √ S06.9 S09.9 Unspecified injury of head
ringan
30 05.64.37 Hernia Inguinal - √ K40.3 K40.9 Unilateral or unspecified inguinal
hernia, without obstruction or
gangrene
31 05.66.01 Tumor Abdomen Bagian - √ D48.7 D36.7 Other specified sites
Kanan Atas
32 05.66.10 Cysta TyroGlossar Cysta Tyroglossar √ Q89.2 Q89.2 Congenital malformations of other
endocrine glands
33 05.66.24 Clavus kaki kiri Clavus Kaki Kiri √ L84 L84 Corns and callosities
34 05.49.70 Appendicitis Akut Appendicitis akut √ K35.0 K35.9 Acute appendicities, unspecified
35 04.97.13 Hernia Inguinal Lateralis HIL sinistra √ K.40.3 K40.9 Unilateral or unspecified inguinal
Sinistra Lepouibilis Lepouibilis hernia, without obstruction or
gangrene
36 06.32.52 Fistel Perianal Fistel Perianal √ K60.2 K60.3 Anal fistula
37 01.88.76 Tumor Mammae Sinistra Tumor Mammae √ D24 D24 Benign neoplasm of breast
sinistra
38 06.31.87 Dysmoroid Cysta Dysmoroid Cysta √ D36.7 D13.5 Extrahepatic bile ducts
39 05.58.20 Apendicitis Acute Appendicitis akut √ K35.9 K35.0 Acute appendicitis with
Perforation Perforation generalized peritonitis
40 05.64.32 Abscess Hepar - √ K75.0 K75.0 Abscess of liver
41 05.63.76 Peritonitis gen. Acausi Peritonitis √ K35.0 K35.0 Acute appendicitis with
perforasi appendicitis generalized acausi generalized peritonitis
perforasi
appendicitis
42 05.63.78 Peritonitis generalized Peritonitis √ K35.0 K35.0 Acute appendicitis with
Appendicitis acute generalized generalized peritonitis
Appendicitis
acute
43 05.67.55 Hemorohoid Fissura ani - √ I84.2 I84.2 Internal haemorrhoids without
complication
44 05.67.52 Fibroma Paha Kanan Fibroma Paha √ D16.2 D21.2 Connective and other soft tissue of

4
 LAMPIRAN 2

lower limb, including hip

45 05.67.17 Vulnus Laceration Ibu jari V. Laceration Ibu √ S91.1 S91.1 Open wound of toe without
kaki kiri jari kaki kiri damage to nail
46 05.68.02 Tumor Mammae Dextra Tumor Mammae √ D24 D24 Benign neoplasm of breast
Gland Atas Dextra gland atas
47 06.26.29 Lipoma Kuduk Lipoma Kuduk √ D36.7 D17.0 Benign lipomatous neoplasm of
skin and subcutaneous tissue of
head, face and neck
48 05.65.61 Hyperemesis Gravidarum Hyperemesis √ O21.0 O21.0 Mild hyperemesis gravidarum
Gravidarum
49 05.56.61 Infeksi Saluran Kemih Infeksi Saluran √ N39.0 N39.0 Urinary tract infection, site not
Kemih specified
50 04.28.18 Hypertensi Hypertensi √ I10 I10 Essential (primary) hypertension
51 03.82.46 Appendicitis akut - √ K35.9 K35.9 Acute appendicitis, unspecified
52 04.52.92 Hypertensi Hypertensi √ I10 I10 Essential (primary) hypertension
53 04.34.99 Dispepsia Dispepsia √ K30 K30 Dyspepsia
54 04.53.46 Hipertensi Hipertensi √ I10 I10 Essential (primary) hypertension
55 00.10.09 KOCH Pulmonary KOCH √ A16.2 A16.2 Tuberculosis of lung, without
Pulmonary mention of bacteriological or
histologi confirmation
56 06.26.19 Gastritis Gastritis √ K29.7 K29.7 Gastritis, unspecified
57 06.22.40 Hypertropi Prostat Grade Hypertropi √ N40 N40 Hyperplasia of prostate
IV Prostat Grade IV
58 06.26.14 Appendicitis Akut Appendicitis akut √ K35.9 K35.9 Acute appendicities, unspecified
59 06.22.30 Dispepsia Dispepsia √ K30 K30 Dyspepsia
60 06.22.26 Demam Thypoid Demam Thypoid √ A01.0 A01.0 Typhoid fever
61 06.22.23 Bronchitis Bronchitis √ J40 J40 Bronchitis, not specified as acute
or chronic
62 06.22.10 ISK ISK √ N39.0 N39.0 Urinary tract infection, site not
specified
63 06.21.89 Tumor Paru Kiri Tumor Paru Kiri √ D14.3 D14.3 Bronchus and lung
64 06.22.02 Hipertensi Hipertensi √ I10 I10 Essential (primary) hypertension

5
 LAMPIRAN 2

65 05.36.01 Low Back Pain Lumbar Low Back Pain √ M54.8 M54.56 Low back pain (lumbar legion)
Lumbar 8
66 06.21.86 Dysentri Baciler Dysentri Baciler √ A03.9 A03.9 Shingellosis, unspecified
67 06.21.91 OMA OMA √ H66.9 H66.9 Otitis media, unspecified
68 06.21.90 Gastritis Erosiva Gastritis Erosiva √ K29.1 K29.1 Other acute gastritis
69 05.21.84 Low Back Pain Low Back Pain √ M54.5 M54.59 Low back pain (site unspecified)
8
70 06.21.86 Anemia Aplastik Anemia Aplastik √ D61.9 D61.9 Aplastic anaemia, unspecified